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PubMed2004

B-type natriuretic Peptide and the right heart.

B-type natriuretic Peptide (BNP) is elevated in conditions with ventricular volume and pressure overload. The physiological, diagnostic and therapeutic role of BNP in right ventricular (RV) dysfunction and pulmonary arterial hypertension (PAH) are reviewed in this article. BNP levels can be used to differentiate between breathless patients with a respiratory disease and those with PAH. BNP has been shown to correlate with mean pulmonary arterial pressure and pulmonary vascular resistance in patients with PAH, whether primary or secondary. BNP is also a predictor of mortality in patients with primary pulmonary hypertension. These are important clinical implications in that a non-invasive blood test may be used to identify patients who require more invasive procedures (such as cardiac catheterization). There is increasing evidence that BNP or NT-proBNP measurements may also be used to guide therapy (e.g. pulmonary vasorelaxants) in PAH. Enhancement of the natriuretic peptide pathway has been shown to reduce cardiac hypertrophy and PAH and hence, there may be therapeutic potential via recombinant BNP or neutral endopeptidase inhibitors in RV dysfunction and PAH.

Fibrosis↗
PubMed2000

Right ventricular long axis function in adults and children with Ebstein's malformation.

OBJECTIVES: To assess right ventricular function in adults and children with Ebstein's anomaly. DESIGN: Prospective study. SETTING: Tertiary referral centre. SUBJECTS: Fifteen patients (8 adults and 7 children) with Ebstein's anomaly and 14 healthy controls. INTERVENTIONS: Transthoracic echocardiography was performed in all. Right ventricular function was assessed from long axis M-mode recordings of the right atrio-ventricular free wall. Total systolic excursion as well as peak shortening and lenghtening rates of the right ventricle were measured. RESULTS: Children and adult patients with Ebstein's anomaly differed in terms of age at diagnosis, the adult group having been diagnosed later 19.8+/-15.8 vs. 5.9+/-6.2 years, P<0.05. Measures of right ventricular long axis function in children with Ebstein's anomaly showed a significantly reduced systolic excursion 1.4+/-0.4 vs. 2.4+/-0.53 cm, P<0.05 and peak lenghtening rate; early 8.04+/-4.3 vs. 11.8+/-2.4 cm/s and late 6.14+/-3.6 vs. 10.6+/-4.3 cm/s, P=0.05 compared to controls. In contrast, measurements of right ventricular long axis function in adults with Ebstein's anomaly showed no significant difference when compared to the control group. Transtricuspid Doppler flow velocities were not different between patient's groups and corresponding controls. CONCLUSION: The right ventricle assessed by this simple, non-invasive technique reveals a significantly reduced systolic and diastolic function in children with Ebstein's malformation compared to controls but a 'normal' right ventricular function comparable to controls in adult patients. Significant right ventricular dysfunction in children with Ebstein's anomaly could account for their earlier presentation. Long term follow up of the right ventricular abnormalities is needed in such children to discover more about the natural history of the disease.

Adult↗
PubMed2002

Measurement of right ventricular volume in healthy term and preterm neonates.

BACKGROUND: Pulmonary hypertension is associated with worse perinatal outcomes in infants with respiratory disorders. In such infants right ventricular dysfunction may result in poor pulmonary blood flow. OBJECTIVE: To evaluate the practicability and repeatability of echocardiographic measurements of right ventricular volume in healthy term and preterm neonates, and to follow changes in right ventricular volume over the first 2 days of life. METHODS: Serial echocardiographic examinations were performed on day 0, 1, and 2 on healthy term and preterm neonates. Two methods of estimating right ventricular volume were assessed: the ellipsoid approximation and Simpson's stacked discs methods. Systolic and diastolic volumes on days 1 and 2 were compared with baseline values on day 0. Term and preterm volumes were compared at the same time points. RESULTS: Thirty five infants were recruited, 18 term and 17 preterm. Right ventricular volumes were significantly lower on day 1 and day 2 than baseline in both term and preterm infants. Median (interquartile range) end systolic and diastolic volumes for term infants on days 0, 1, and 2 were 1.04 (0.88-1.44), 0.82 (0.70-1.03), 0.92 (0.72-0.97) ml/kg and 2.21 (2.10-2.75), 2.05 (1.81-2.38), 1.91 (1.81-2.13) ml/kg respectively. In preterm infants the values were 1.09 (0.91-1.16), 0.72 (0.54-0.91), 0.61 (0.54-0.76) ml/kg and 2.09 (1.71-2.25), 1.47 (1.23-1.98), 1.43 (1.22-1.78) ml/kg respectively. CONCLUSION: Right ventricular volume decreases over the first 2 days of life in healthy term and preterm infants.

Cardiac Output↗
PubMed1992

Right ventricular assist devices and the surgical treatment of right ventricular failure.

Treatment of patients with severe right ventricular dysfunction follows a continuum of progressive therapies. If optimization of volume status and inotropic support do not adequately improve right ventricular function, higher levels of mechanical circulatory support are required. A right-sided intraaortic balloon pump has been helpful in such circumstances. The centrifugal pump and the artificial ventricle provide the most effective long-term circulatory support for patients with right ventricular or biventricular failure after cardiopulmonary bypass, myocardial infarctions, or as a bridge to cardiac transplantation. All of these support measures still carry a high morbidity and mortality. Survival in approximately one third of these high-risk patients can be expected with the use of right ventricular assist devices. Cardiopulmonary bypass has also been effective for circulatory support of patients with massive pulmonary emboli.

Cardiopulmonary Bypass↗
PubMed1990

[Congestive heart failure in the elderly: severe tricuspid regurgitation by two-dimensional Doppler echocardiography].

We studied five cases of atrial fibrillation in the elderly showing severely decreased exercise tolerance (NYHA III) and normal left ventricular function. There were no signs of classical tricuspid regurgitation. Both atria were enlarged and right ventricular sizes were shown by two-dimensional echocardiography to have mildly increased. Two-dimensional Doppler echocardiography revealed severe tricupid regurgitation but at a maximal velocity less than 2.3 m/sec, meaning that right ventricular pressure was not increased. Cardiac output (CO) and circulating blood volume (BV), measured by radiocardiography showed CO to have decreased and BV to have increased. No intracardiac shunt was detected. The cause of this decreased exercise tolerance in the group in our study is thought to be right ventricular dysfunction due to the aging process. This also occurs in a similar pattern in younger people who have arrhythmogenic right ventricular dysplasia (ARVD), Uhl's disease, or right ventricular dilated cardiomyopathy.

Aged↗
PubMed2004

[Lung function in cardiac dysfunction].

OBJECTIVE: The alterations in lung function caused by heart failure were first described some decades ago. The advent of new tools for the diagnosis and investigation of heart disease, such as echocardiography, has subsequently made it possible to classify cardiac dysfunction with greater precision. The objective of this study was to analyze and compare a series of lung function and gas exchange variables in patients who had been classified into 4 groups according to type of heart disease as diagnosed by echocardiography. MATERIALS AND METHOD: Emergency room patients whose main symptom was acute dyspnea caused by cardiac or respiratory disease were included in the study. The final sample comprised 71 patients whose echocardiogram revealed cardiac dysfunction. Spirometry was carried out and resting arterial blood gases measured in this group. RESULTS: Of the 71 patients with cardiopathy, 31 had systolic dysfunction, 27 diastolic dysfunction, 7 cor pulmonale, and 6 primary valve disease. Spirometry revealed a generally obstructive pattern, more marked in the group with cor pulmonale. Analysis of arterial blood gases revealed slight hypoxemia with normocapnia in all groups, but this was more accentuated in the patients with cor pulmonale and diastolic dysfunction. An analysis of the correlations (Pearson's r) between cardiac and pulmonary variables revealed the statistically significant associations between cardiac mass and other variables to be as follows: forced vital capacity r=0.34 (P=.02), forced expiratory volume in one second r=0.526 (P=.0001), forced expiratory volume in one second as a percentage of predicted r=0.3 (P=.037), and forced midexpiratory flow rate r=0.31 (P=.03). The correlation between left ventricular ejection fraction and PaO2 was r=-0.312 (P=.01); the correlation between left ventricular end-diastolic diameter and PaO2 was r=0.369 (p=.006). CONCLUSIONS: In patients with cardiac dysfunction, spirometry reveals a generally obstructive pattern, which is more accentuated in patients with right ventricular dysfunction owing to the existence of prior lung disease. The associations found between the cardiac and lung function variables do not help the physician to determine the predominant diagnosis for a patient more precisely or to establish a prognosis.

Adult↗
PubMed1992

Late tricuspid regurgitation following mitral valve surgery.

The development of late tricuspid regurgitation is an important complication of mitral valve surgery, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined, but it is usually attributable to a functional abnormality of the tricuspid valve. Whilst its development may indicate an increased afterload on the right heart as a consequence of persistent pulmonary hypertension, mitral prosthetic dysfunction, progressive aortic valve disease or left ventricular failure, late tricuspid regurgitation may also develop in the absence of these factors and then may reflect right ventricular dysfunction and/or a localized abnormality of the tricuspid anulus. Failure to recognize and correct tricuspid regurgitation at the time of initial surgery may also account for many cases of tricuspid regurgitation but its re-appearance following tricuspid annuloplasty is uncommon and usually reflects a failure of the mitral prosthesis. A reduction in the prevalence of late tricuspid regurgitation is an important objective in view of the high operative mortality and disappointing long term results associated with reoperation for tricuspid regurgitation. This may be best achieved through combining earlier mitral valve surgery with the accurate detection and liberal correction of accompanying tricuspid incompetence at the time of initial surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiography, Doppler↗
PubMed2000

Right ventricular infarction--diagnosis and treatment.

Right ventricular infarction (RVI) as assessed by various diagnostic methods accompanies inferior-posterior wall myocardial infarction (MI) in 30 to 50% of patients. Recognition of the syndrome of RVI is important as it defines a significant clinical entity, which is associated with considerable immediate morbidity and mortality and has a well-delineated set of priorities for its management. Patients may clinically present with hypotension, elevated jugular venous pulse (JVP), and occasionally shock, all in the presence of clear lung fields. The ST-segment elevation of > or = 0.1 mV in the right precordial leads V4R is a readily available electrocardiographic sign used for diagnosis of RVI. Other diagnostic approaches for assessing RVI include echocardiography, radionuclide ventriculography, technetium pyrophosphate scanning, and hemodynamic measurements. The proper management of RVI includes volume loading to maintain adequate right ventricular preload, ionotropic support, and maintenance of atrioventricular synchrony. Reperfusion therapy should be initiated at the earliest signs of right ventricular dysfunction. Finally, complete recovery over a period of weeks to months is a rule in a majority of patients, suggesting right ventricular "stunning" rather than irreversible necrosis has occurred.

Animals↗
PubMed2003

Assessment of right ventricular diastolic filling parameters by Doppler echocardiography.

BACKGROUND: Right ventricular diastolic function has been evaluated in various diseases by the pulsed Doppler technique. Right ventricular diastolic filling parameters show changes with age, heart rate and respiration. Evidences of diastolic left and right ventricular dysfunctions have been reported by echocardiographic studies in asthmatic patients. In the present study, before and after treatment of asthma the right ventricular diastolic filling parameters were compared in children with moderate asthma by Doppler echocardiography (a non-invasive technique). METHODS: The study group consisted of 20 children (eight girls, 12 boys) with asthma. During the present study these patients were treated with inhaled steroid and beta-2 agonist daily. Before treatment all patients were evaluated by Doppler echocardiography. At 4-6 weeks after treatment 15 patients that had shown improvement in their symptoms according to the symptom score were also evaluated by Doppler echocardiography. RESULTS: The mean age was 8.6 +/- 2.69 years and mean period of symptoms were 56.4 +/- 35.8 months. When compared with results of echocardiography before and after treatment, the right ventricular diastolic filling parameters (acceleration time: P < 0.01, deceleration time: P < 0.01 and isovolumetric relaxation time: P < 0.05) were found to be significantly different. CONCLUSIONS: We observed significant improvement of right ventricular diastolic filling parameters by Doppler echocardiography after treatment in children with asthma.

Adolescent↗
PubMed1987

Transposition of the great arteries: late results in adolescents and adults after the Mustard procedure.

A selected group of 18 patients aged 15-27 years with transposition of the great arteries and a previous Mustard procedure were evaluated to determine their functional ability and clinical state. Arrhythmias were common, occurring at some time in 16/18 (89%). Arrhythmia was serious in four; two of them required pacing and two had cardiac arrests, one resulting in death. Seven (41%) had right ventricular dysfunction; this was progressive in three. Tricuspid regurgitation was present in seven (41%); it occurred in patients with normal and reduced right ventricular ejection fractions. Regurgitation became progressively worse as the right ventricle dilated. Left ventricular function was well preserved in most patients. Fourteen (82%) of this pioneer group were leading normal lives (ability index 1 or 2). Although these results are acceptable concern remains about the probability of deteriorating right ventricular function.

Arrhythmias, Cardiac↗
PubMed1991

Effect of single lung transplantation on pulmonary hypertension in patients with end stage fibrosing lung disease.

OBJECTIVE: To investigate the effect of successful single lung transplantation on pulmonary haemodynamic variables and right ventricular function. DESIGN: Pulmonary haemodynamic variables and right ventricular function were measured at right heart catheterisation after single lung transplantation. The results were compared with the preoperative pulmonary haemodynamic variables measured at the time of assessment for transplantation. SETTING: A tertiary referral centre. PATIENTS: Five survivors of single lung transplantation performed for end stage lung disease. INTERVENTIONS: Cardiac catheterisation in all five patients at a mean of 18 months postoperatively. Preoperative catheter data were available for comparison in four. Right heart pressures and cardiac output were measured and right ventricular angiography was performed. Perfusion scans performed for clinical reasons were used to assess the percentage of cardiac output passing through each lung. MAIN OUTCOME MEASURES: Right heart pressures, cardiac output, right ventricular function, percentage perfusion to lungs. RESULTS: After operation mean peak right ventricular pressure fell from 53 mm Hg to 33 mm Hg, mean pulmonary artery pressure from 33 mm Hg to 18 mm Hg, total pulmonary resistance from 11.2 U x m2 to 5.8 U x m2, and pulmonary arteriolar resistance from 8.9 U x m2 to 3.6 U x m2. Pulmonary artery wedge pressure and cardiac index were unchanged. Right ventricular function improved in all patients. The transplanted lung received most of the cardiac output. CONCLUSION: In patients with moderate pulmonary hypertension and right ventricular dysfunction secondary to end stage fibrosing lung disease single lung transplantation was followed by an improvement in pulmonary haemodynamic variables and right ventricular function.

Blood Pressure↗
PubMed2002

Modern treatment of pulmonary embolism.

Modern treatment of acute pulmonary embolism requires rapid and accurate diagnosis followed by risk stratification to devise an optimal management strategy. Patients at low risk have good outcomes simply with intensive anticoagulation treatment. Higher-risk patients may require more aggressive intervention with thrombolysis or embolectomy. Clinical risk factors for an adverse outcome include increasing age, cancer, congestive heart failure, systemic arterial hypotension, chronic obstructive pulmonary disease and right ventricular dysfunction. A promising approach is the Geneva Prognostic Score, which is based upon a rapid clinical assessment. On physical examination, signs of right ventricular failure, including distended jugular veins and a right-sided S3 gallop, should be looked for. The electrocardiogram may show evidence of right ventricular strain with a new right bundle branch block or T wave inversion in leads V1-V4. The troponin level may be elevated as a marker of cardiac injury and right ventricular microinfarction, even in the absence of coronary artery disease. The most useful imaging marker of high risk is the presence of moderate or severe right ventricular dilatation and hypokinesis on the echocardiogram, especially with progressively worsening right ventricular function despite intensive anticoagulation treatment. Patients at high risk should be considered for thrombolytic therapy or embolectomy rather than management with anticoagulation therapy alone. Special care must be taken to avoid thrombolytic therapy among patients who might be susceptible to intracranial haemorrhage. Intracranial haemorrhage reached a surprisingly high rate of 3.0% in the International Cooperative Pulmonary Embolism Registry of 2,454 prospectively evaluated acute pulmonary embolism patients at 52 hospitals in seven countries. An alternative approach to patients at high risk is a catheter-based or open surgical embolectomy. It is crucial to refer these patients as quickly as possible, rather than delaying intervention until cardiogenic shock has ensued. Fortunately the current tools for risk stratification provide an "early window" for prognostication and can help the coordination of a definitive treatment plan with optimal results.

Acute Disease↗
PubMed2002

Pulmonary embolism.

The natural history of pulmonary embolism (PE) is incompletely characterized, because most episodes of PE go undetected, the clinical presentation mimics so many other common and uncommon diseases, the sensitivity and specificity of the diagnostic tests are poorly defined, and even detection at autopsy is difficult and requires close examination of the pulmonary arteries. Yet PE is a significant cause of morbidity and mortality in the hospitalized patient, and one reason for its extremely high incidence is the failure of physicians to provide adequate prophylaxis to patients who are at risk of developing venous thromboembolism. The mortality rate for PE is less than 8% when the condition is recognized and treated correctly but approximately 30% when untreated. Pulmonary arteriography is still the gold standard in diagnosing pulmonary emboli, but several other imaging modalities have been used to diagnose pulmonary emboli in recent years, including transthoracic and transesophageal echocardiography, magnetic resonance angiography, spiral computerized tomography, and ventilation-perfusion lung scanning. The treatment modality chosen depends directly on the clinical presentation of the patient. Low molecular weight heparin may be equal or superior in efficacy to unfractionated heparin for the treatment of deep venous thrombosis and PE. Thrombolytic therapy can be considered for patients with hemodynamic instability, those with right ventricular dysfunction, and young patients with a massive PE despite a normal right ventricle on echocardiography. In those patients who cannot receive anticoagulation therapy or thrombolysis, or who remain at high risk, an inferior vena cava filter should be placed.

Angiography↗
PubMed2000

Right ventricular function of patients with septic shock: clinical significance.

OBJECTIVE: To understand the effect of right ventricular dysfunction on circulatory supportive therapy in patients with septic shock. METHODS: 25 patients with septic shock who were admitted consecutively to the intensive care unit (ICU) of Peking Union Medical College Hospital were observed prospectively. Hemodynamic profile of the left side and right side heart was monitored with right ventricular ejection fraction catheter and transthoracic echocardiography. Intramucosal pH (pHi) and oxygen delivery were also monitored to illustrate any relation with patient outcome. RESULTS: Stroke volume index (SVI) and right ventricular ejection fraction (RVEF) were significantly higher in survivors than in nonsurvivors (P < 0.01 and < 0.05, respectively). The pulmonary vascular resistance index (PVRI) was significantly lower in survivors (P < 0.01). At the onset of shock, the left ventricular end-diastolic volume index (LVEDVI) of both groups was very low, and steadily increased in survivors but not in nonsurvivors. Left ventricular ejection fraction (LVEF) and systemic vascular resistance index (SVRI) decreased during treatment, which were not different in both groups. Right ventricular end-diastolic volume index (RVEDVI) increased in both survivors and nonsurvivors. Oxygen delivery of nonsurvivors was significantly lower than that of survivors. LVEDVI and RVEF were correlated with SVI in both survivors and nonsurvivors. CONCLUSIONS: The impairment of right heart function may be more severe than that of left heart function in the patients with early septic shock. "Right heart priority" must be seriously considered in supportive treatment of patients with septic shock. The present treatment of septic shock has significant limitations, and even aggravates the existing cardiac dysfunction.

Adult↗
PubMed1984

[Effect of chronic pressure and volume stress on the function of the right ventricle].

Biplane right ventricular angiography was performed in 36 patients with chronic pressure overload of the right ventricle; 12 patients additionally had tricuspid insufficiency (TI). There were 4 subgroups: patients with systolic pulmonary artery pressure less than or equal to 40 mm Hg without (group I, n = 10) and with TI (group II, n = 6), as well as patients with systolic pulmonary artery pressure greater than 40 mm Hg without (group III, n = 14) and with TI (group IV, n = 6). Compared with the normal volumes of groups I and III, a significant increase in end-diastolic right ventricular volumes (p less than 0.01) was found in groups II and IV with 112.2 +/- 22.3 ml/m2 and 116.3 +/- 27.4 ml/m2, respectively. In both groups II and IV end-systolic volumes were also significantly increased, with 51.0 +/- 10.3 ml/m2 in group II and 49.7 +/- 11.3 ml/m2 in group IV. Right ventricular ejection fraction was 53.8 +/- 11.9% in group II, 57.3 +/- 8.5% in group III and 57.8 +/- 7.3% in group IV. There was no significant difference between the ejection fraction of these groups in comparison to the normal ejection fraction of group I with 63.4 +/- 10.9%. The results suggest that the right ventricle can compensate for moderate chronic pressure and volume overload using the Frank-Starling mechanism. Overall right ventricular dysfunction is not determined primarily by the loading conditions alone. Local myocardial and septal involvement is suspected to be an important determinant of right ventricular function.

Aortic Valve Insufficiency↗
PubMed2001

Thermal therapy for congestive heart failure: estimation by TEI index.

Systolic dysfunction commonly coexists with diastolic dysfunction in patients with congestive heart failure due to myocardial disease. Also, right ventricular dysfunction is frequently associated with left ventricular dysfunction. The Doppler total ejection isovolume (TEI) index, a combined measurement of systolic and diastolic myocardial performance, is more reflective of overall cardiac function than systolic or diastolic function alone in both ventricles, and provides a conceptually new measure of global cardiac function. Single sauna bathing improves acute hemodynamics and repeated sauna therapy improves cardiac function and clinical symptoms in patients with heart failure. More recently, improvement of vascular endothelial function were observed by repeated sauna therapy in patients with heart failure. The TEI index, combining systolic and diastolic myocardial function, is a promising tool for the quantitative assessment of global cardiac function before and after thermal therapy.

Diastole↗
PubMed1982

Recovery of right ventricular function following repair of acute ventricular septal defect.

Ventricular septal defect is a serious complication of acute myocardial infarction with a high mortality rate. Right ventricular dysfunction, which frequently accompanies septal defect, can be due to several etiologies. We describe two cases of septal defect following infarction, with sequential studies of right and left ventricular function. Right ventricular infarction was found in both patients. Postoperatively, the right ventricular ejection fraction improved significantly. The pathophysiology and expectation for recovery are discussed.

Aged↗